- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.78 / $1,201.78 / $1,201.78
| Facility | | $1,201.78 | $1,201.78 | $1,201.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,201.78 / $1,201.78 / $1,201.78
| Professional | | $1,201.78 | $1,201.78 | $1,201.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.95 / $1.00 / $1.00
| Facility | | $0.95 | $1.00 | $1.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.78 / $1,438.00 / $2,400.00
| Facility | | $1,201.78 | $1,438.00 | $2,400.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,063.00 / $1,597.44 / $3,584.00
| Facility | | $1,063.00 | $1,597.44 | $3,584.00 |